Ch 63: Management of Patients with Neurologic Trauma

80 mL/hr Pg. 2059 20/15 × 60 = 80 mL/hr

34. The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

b) Fever and change in urine clarity Pg. 2083 Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

56. A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? a) Lower back pain b) Fever and change in urine clarity c) Burning sensation on urination d) Frequency of urination

c) Herniation Pg. 2058-2059 Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.

57. Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? a) Autoregulation b) Monro-Kellie hypothesis c) Herniation d) Cushing's response

a) Meticulous cleanliness Pg. 2078 Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.

58. Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? a) Meticulous cleanliness b) Continuous use of an indwelling catheter c) Allowing the client to choose the position of comfort d) Avoidance of all lotions and lubricants

d) Spinal shock Pg. 2075-2076 Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.

1. The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? a) Paraplegia b) Tetraplegia c) Cardiogenic shock d) Spinal shock

c) Spasticity Pg. 2081-2084 Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

10. Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? a) Myoclonus b) Ataxia c) Spasticity d) Akathisia

d) Monitoring is needed as rapid neurologic deterioration may occur Pg. 2058-2059 The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.

11. A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? a) Bleeding continues into the intracerebral area b) Symptoms will evolve over a period of 1 week c) The crash cart with defibrillator is kept nearby d) Monitoring is needed as rapid neurologic deterioration may occur

a) Subdural hematoma Pg. 2056 A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

12. Which condition occurs when blood collects between the dura mater and arachnoid membrane? a) Subdural hematoma b) Epidural hematoma c) Extradural hematoma d) Intracerebral hemorrhage

b) Alteration in level of consciousness (LOC) Pg. 2059 The first sign of possible subdural hematoma is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated.

13. A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? a) Bradycardia b) Alteration in level of consciousness (LOC) c) Slurred speech d) Decreased heart rate

b) Subdural Pg. 2059 A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

14. Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a) Epidural b) Subdural c) Cerebral d) Intracerebral

a) Maintain cerebral perfusion pressure from 50 to 70 mm Hg Pg. 2058-2068 The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

15. The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? a) Maintain cerebral perfusion pressure from 50 to 70 mm Hg b) Restrain the client, as indicated c) Administer enemas, as needed d) Position the client in the supine position

b) Risk for injury Pg. 2060 Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

16. A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? a) Disturbed sensory perception (visual) b) Risk for injury c) Impaired verbal communication d) Dressing or grooming self-care deficit

c) An intracerebral hematoma Pg. 2059-2060 Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

17. A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? a) An epidural hematoma b) An extradural hematoma c) An intracerebral hematoma d) A subdural hematoma

c) It allows for stabilization of the cervical spine along with early ambulation Pg. 2075 Halo devices provide immobilization of the cervical spine while allowing early ambulation.

18. A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? a) The patient can remove it as needed b) It is less bulky and traumatizing for the patient to use c) It allows for stabilization of the cervical spine along with early ambulation d) It is the only device that can be applied for stabilization of a spinal fracture

d) Vomits Pg. 2058-2060 Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

19. A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client a) Reports generalized weakness b) Sleeps for short periods of time c) Reports a headache d) Vomits

d) Body temperature Pg. It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.

2. When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? a) Extreme thirst b) Intake and output c) Nutritional status d) Body temperature

c) Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue Pg. 2058 Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Therefore the other options are incorrect.

20. A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? a) Contusions are deep brain injuries b) Contusions are microscopic brain injuries c) Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue d) Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow

d) Autonomic dysreflexia Pg. 2078 Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.

21. You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? a) Paraplegia b) Areflexia c) Tetraplegia d) Autonomic dysreflexia

c) "They help prevent the development of contractures" Pg. 76 Clients are at high risk for the development of contractures as a result of disuse syndrome due to the musculoskeletal system changes brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises to prevent footdrop. Range-of-motion exercises are not done to stabilize total body functioning or restore skeletal integrity. Exercise programs are used to prepare to function in the absence of leg function.

22. A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make? a) "They prepare you to function in the absence of your leg function" b) "They aid in restoring your skeletal integrity" c) "They help prevent the development of contractures" d) "They help stabilize total body functioning"

a) Acute Pg. 2059 Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.

23. A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? a) Acute b) Subacute c) Chronic d) Intracerebral

d) Irrigates the wound to remove debris Pg. 2056 Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.

24. A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? a) Administers an oral analgesic for pain b) Shaves the hair around the wound c) Administers acetaminophen (Tylenol) for headache d) Irrigates the wound to remove debris

c) Widened pulse pressure Pg. 2056 Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

25. Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? a) Increased respirations b) Decreased body temperature c) Widened pulse pressure d) Increased pulse

c) Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Pg. 2068 Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

26. For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? a) So that the patient will not have a respiratory arrest b) To prevent secondary brain injury c) Because hypoxemia can create or worsen a neurologic deficit of the spinal cord d) To increase cerebral perfusion pressure

b) Place in a seated position Pg. 63 Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without spinal cord injury (SCI). It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. The first action to take is to place the client in a seated position to lower the blood pressure. Next, the bladder can be assessed for distention, the skin assessed for areas of pressure, and the rectum assessed for a fecal mass, which can all be the reasons for the onset of the symptoms.

27. A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first? a) Examine the rectum for a fecal mass b) Place in a seated position c) Assess the skin for areas of pressure d) Palpate the bladder for distention

d) Decerebrate Pg. 2060 Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

28. When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? a) Flaccid b) Decorticate c) Normal d) Decerebrate

a) Severe TBI Pg. 2063 A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

29. A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: a) Severe TBI b) Moderate TBI c) Brain death d) Mild TBI

b) Absence of reflexes along with flaccid extremities Pg. 2075-2076 During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

3. A client with quadriplegia is in spinal shock. What finding should the nurse expect? a) Positive Babinski's reflex along with spastic extremities b) Absence of reflexes along with flaccid extremities c) Spasticity of all four extremities d) Hyperreflexia along with spastic extremities

a) Bradypnea b) Hypertension d) Bradycardia Pg. 2064-2065 The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

30. At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. a) Bradypnea b) Hypertension c) Hypotension d) Bradycardia e) Tachycardia

a) Monitoring the patency of an indwelling urinary catheter Pg. 2078 A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.

31. Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? a) Monitoring the patency of an indwelling urinary catheter b) Placing the client in Trendelenburg's position c) Administering zolpidem tartrate (Ambien) d) Assessing laboratory test results as ordered

d) Decrease the potential for brain damage Pg. 2058-2059 It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures.

32. A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: a) Follow hospital protocol b) Prevent embolism c) Assess for infection d) Decrease the potential for brain damage

a) Look for signs of increased intracranial pressure Pg. 2058-2060 The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

33. A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? a) Look for signs of increased intracranial pressure b) Have the client avoid physical exertion c) Emphasize complete bed rest d) Look for a halo sign

c) Keep the client's neck in a neutral position (no flexing) Pg. 2068 To assist in controlling ICP in clients with severe brain injury, the following are recommended: elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired).

35. A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? a) Cluster all procedures together b) Keep the head of the client's bed flat c) Keep the client's neck in a neutral position (no flexing) d) Avoid sedation

b) Setting priorities for nursing interventions c) Anticipating needs and complications d) Initiating rehabilitation e) Making nursing assessments Pg. 2064 The nursing interventions for the patient with a head injury are extensive and diverse. They include making nursing assessments, setting priorities for nursing interventions, anticipating needs and complications, and initiating rehabilitation.

36. The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply. a) Ensuring that the patient regains full brain function b) Setting priorities for nursing interventions c) Anticipating needs and complications d) Initiating rehabilitation e) Making nursing assessments

a) Ineffective cerebral tissue perfusion related to increased intracranial pressure Pg. 2064 Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.

37. A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? a) Ineffective cerebral tissue perfusion related to increased intracranial pressure b) Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction c) Disturbed thought processes related to brain injury d) Ineffective airway clearance related to brain injury

d) "I can apply powder under the liner to help with sweating" Pg. 2075-2078 Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

38. The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? a) "I'll check under the liner for blisters and redness" b) "I will change the vest liner periodically" c) "If a pin becomes detached, I'll notify the surgeon" d) "I can apply powder under the liner to help with sweating"

b) Ecchymosis over the mastoid Pg. 2057 With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

39. The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? a) Drainage of cerebrospinal fluid from the ears b) Ecchymosis over the mastoid c) Bruising under the eyes d) Drainage of cerebrospinal fluid from the nose

b) Tachycardia Pg. 2064-2065 Cushing's triad, or Cushing reflex, is a nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration. More rapid heart rate (tachycardia) is not a component of the triad.

4. Which of the following is not a manifestation of Cushing's triad (Cushing reflex)? a) Irregular respiration b) Tachycardia c) Hypertension d) Widening pulse pressure

a) Glasgow Coma Scale of 6 Pg. 2062 The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.

40. A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: a) Glasgow Coma Scale of 6 b) Absence of brain stem reflexes c) Coma d) Apnea

d) C5 Pg. 2070-2074 At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.

41. A client with a spinal cord injury has full head and neck control when the injury is at which level? a) C1 b) C2 to C3 c) C4 d) C5

d) C5 Pg. 2074 At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

42. At which of the following spinal cord injury levels does the patient have full head and neck control? a) C2 b) C4 c) C3 d) C5

b) T6 Pg. 2078 Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

43. Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? a) T10 b) T6 c) S2 d) L4

c) Severe hypertension, slow heart rate, pounding headache, sweating Pg. 2079 Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.

44. Which are characteristics of autonomic dysreflexia? a) Severe hypotension, tachycardia, nausea, flushed skin b) Severe hypertension, tachycardia, blurred vision, dry skin c) Severe hypertension, slow heart rate, pounding headache, sweating d) Severe hypotension, slow heart rate, anxiety, dry skin

a) Motor vehicle crashes Pg. 2070 The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.

45. The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is a) Motor vehicle crashes b) Falls c) Sports-related injuries d) Acts of violence

b) To continue IV administration of other scheduled medications Pg. 2068 When the client isn't sedated, he may make attempts to remove the ET tube without realizing what he's doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.

46. A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: a) She'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube b) To continue IV administration of other scheduled medications c) Nutritional protocol will be effective after the client sedation therapy is tapered d) Payment status will change if the client isn't sedated

b) Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes Pg. 2080 Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

47. A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? a) Reassure the client that a headache is expected and will go away without treatment b) Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes c) Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered d) Notify the physician; a headache is an early sign of worsening neurologic status

d) Record intake and output Pg. 2065 A record of intake and output is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. Excessive output will alert the nurse to possible fluid imbalance early in the process.

48. A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? a) Assess frequent vital signs b) Reposition frequently c) Assess for pupillary response frequently d) Record intake and output

d) Traction with weights and pulleys Pg. 2075 Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

49. The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? a) Cast b) Cervical collar c) Turning frame d) Traction with weights and pulleys

a) Maintain a diet for the client that is high in protein, vitamins, and calories Pg. 2082 To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

5. A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? a) Maintain a diet for the client that is high in protein, vitamins, and calories b) Keep accurate intake and output c) Avoid range of motion exercises for the client because of spasms d) Watch closely for signs of urinary tract infection

d) Rebound hypotension Pg. 2078 When the cause is removed and the symptoms abate, the blood pressure goes down. The antihypertensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.

50. A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? a) Rebound hypertension b) Spinal shock c) Urinary tract infection d) Rebound hypotension

b) Autonomic dysreflexia Pg. 2078 Characteristics of this acute emergency are as follows: Severe hypertension; Slow heart rate; Pounding headache; Nausea; Blurred vision; Flushed skin; Sweating; Goosebumps (erection of pilomotor muscles in the skin); Nasal stuffiness; and Anxiety. The symptoms in the scenario are not symptoms or concussion, spinal shock, or contusion.

51. The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? a) Concussion b) Autonomic dysreflexia c) Spinal shock d) Contusion

a) Insertion of a nasogastric tube Pg. 2078 Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary.

52. The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? a) Insertion of a nasogastric tube b) Bowel surgery c) Digital stimulation d) A large volume enema

c) Basilar skull fracture Pg. 2057 A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

53. The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? a) Frontal skull fracture b) Occipital skull fracture c) Basilar skull fracture d) Temporal skull fracture

b) Autonomic dysreflexia Pg. 2078 Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

54. A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? a) Thrombophlebitis b) Autonomic dysreflexia c) Orthostatic hypotension d) Spinal shock

a) Sweating Pg. 2078 Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.

55. A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? a) Sweating b) Rapid heart rate c) Slight headache d) Runny nose

d) Apply an external urinary sheath catheter Pg. 2058-2066 A strategy the nurse can implement to prevent client injury is to use an external sheath catheter for a male client if incontinence occurs. Because prolonged use of an indwelling catheter inevitably produces infection, the client may be placed on an intermittent catheterization schedule. Opioids are contraindicated because they depress respirations, constrict the pupils, and alter responsiveness. Providing adequate lighting to prevent visual hallucinations is recommended. Repositioning the client every 2 hours maintains skin integrity.

59. The nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client? a) Provide a dimly lit room b) Administer opioids to the client c) Turn and reposition the client every 2 hours d) Apply an external urinary sheath catheter

c) Insertion of a nasogastric (NG) tube Pg. 2056-2058 Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

6. The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? a) Urine testing for acetone b) Serum sodium concentration testing c) Insertion of a nasogastric (NG) tube d) Out of bed to the chair three times a day

a) An area of bruising over the mastoid bone Pg. 2056-2057 Battle sign may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea.

7. The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation? a) An area of bruising over the mastoid bone b) A bloodstain surrounded by a yellowish stain on the head dressing c) Escape of cerebrospinal fluid from the client's ear d) Escape of cerebrospinal fluid from the client's nose

c) Risk for injury related to neurologic deficit Pg. 2058 Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety.

8. A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? a) Disturbed sensory perception (visual) related to neurologic trauma b) Impaired verbal communication related to confusion c) Risk for injury related to neurologic deficit d) Feeding self-care deficit related to neurologic trauma

c) Burr holes Pg. 2059 An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.

9. The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? a) Hypophysectomy b) Application of Halo traction c) Burr holes d) Insertion of Crutchfield tongs